New Adult Patient Form

"*" indicates required fields

Step 1 of 2

Full Legal Name*

Address*

Address City Province Postal Code Country

Phone*

Cell

Email*

Enter Email Confirm Email

Date of Birth*

Gender*

Male

Female

Emergency Contact Name*

Emergency Contact Phone Number*

Physician's Name (if known)

Physician's Phone Number (if known)

1. Have you seen your physician in the last 18 months?*

Yes

2. When was your last dental visit?*

2b. What was the reason for your last dental visit?*

3. Are you currently taking any prescription medications, non-prescription drugs or herbal supplements of any kind? Are you currently having any therapies that could affect your immune system (i.e. radiotherapy, organ transplant, chemotherapy)*

Yes

3b. Please list

4. Have you ever had a serious illness or hospitalization?*

Yes

4b. Please list

5. Are you allergic or have you reacted adversely to any drug/ medicine or latex? e.g. local anesthetic (freezing), penicillin or sulpha drugs.*

Yes

5b. Please list

6. Do you now or have you ever had Hepatitis A,B,or C, HIV or AIDS?*

Yes

6b. Please list

7. Have you ever had abnormal bleeding associated with previous extractions, surgery or trauma?*

Yes

8. Do you have trouble opening your jaw/TMJ problems?*

Yes

9. Do you take blood thinners daily? e.g. Aspirin, Plavix, Warfarin.*

Yes

9b. Please list

10. Are you breastfeeding, pregnant or think you might be?

Yes

11. Do you smoke or chew tobacco products?

Yes

11b. How many cigarettes do you smoke per day?

12. Do you have or have had any of the following conditions or treatment?

Rheumatic Fever or Autoimmune disease

Heart disease, heart attack, high/low blood press, pacemaker

Diabetes, kidney disease

Alcohol/drug dependency

Asthma Chest pain, shortness of breath

Prosthetic joint, Bone, muscle or joint disorders

13. Do you snore?*

Yes

14. Do you have any concerns about the appearance of your teeth/gums/smile?*

Yes

15. Have you ever been told that you require pre-medication with antibiotics prior to dental procedures?

Yes

16. How did you hear about us? (Please let us know who it was so we can thank them)

Dynamic Dental Privacy/Office Policy Consent Form

Thank you for choosing us as your dental care provider. We are committed to protecting our patients’ personal information in a responsible and professional manner.

Personal information

In order to properly serve you, we must gather personal information. This information helps us open and update your dental file, to invoice patients for services provided, to process credit card payments, or to collect unpaid accounts. It is also necessary to process insurance claims and third-party health benefits. Lastly, we use it to send appointment reminders as well as information about our dental practice.

Financial Policy

Payment for services rendered are due the day the services have been performed, unless arrangements have been made in advance. If you have dental insurance, we are happy to invoice your insurance company directly on your behalf. In order to provide this service, we ask that a credit card be left on file. Should there be a balance left after your dental insurance has paid their portion, we will send a statement with the balance, and if it is not paid within 30 days, we will charge the credit card on file. Any deductibles or co-payments are due at the time of service. Any portion not paid by your insurance company is your responsibility.

Insurance Policy

We are happy to provide direct billing to insurance companies for our patients. Please keep in mind that your insurance benefits are a contract between you and your insurance provider, and we are not a party to that contract. Due to the Canadian Personal Privacy Act, we are unable to access any specific information from your insurance company regarding your dental plan. It is your responsibility to know the parameters of your coverage, such as annual maximums, frequencies, renewal dates, and any other limitations. We understand that many patients would like to know their insurance coverage prior to consenting to recommended treatment and are happy to provide pre-determinations when possible. Please understand that these are only estimates and are not a guarantee of insurance payment.

Appointment Reminders

As a courtesy, we send out reminder emails 1 week prior to a booked appointment, and if unconfirmed, we will send a text message 3 days prior. If the appointment remains unconfirmed, we will call you 1-2 days prior to your appointment. We require an email address and mobile phone number in order to send the reminders. Although we make every effort to contact you prior to any appointment, it is ultimately your responsibility to ensure that you will be at your appointment. Due to a continuous high demand in prime appointment times, we require a minimum of 24 hours’ notice should you need to reschedule or cancel an appointment. Because we value your time, we do not double book our clients. As such, your appointment is valuable time that the dentist or hygienist have reserved specifically for you. In any case where insufficient notice is given a $50.00 missed appointment fee may be charged to you, or we may require you to prepay to reserve your next appointment.

Medical Information

We collect medical and dental information in order to ensure that we are able to properly treat you as a patient. We may share that information with dental or medical professionals in situations where we are referring you, with your consent, for specialized treatment. Our dental software, ClearDent is one of only two HIIPAA compliant dental software packages available in Canada (as of 2015).

Our Mission

At Dynamic Dental, our goal is for you to have a pleasant experience in our office. We strive to serve you to the best of our ability in helping you attain a high level of overall oral health.

Dentists are regulated by the Alberta Dental Association and College which may inspect our records and interview our team members as part of its regulatory activities in the public interest. Thank you for understanding our financial/privacy policy. Please let us know if you have questions or concerns.

Permit for Treatment

I consent to the performing of the dental and oral surgical procedures agreed to be necessary and advisable, including the use of local anesthetic as indicated and I will assume the responsibility for fees associated with those procedures.

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I consent to the collection, use or disclosure of personal information as required for my own or my dependents dental care, as stated above.

This field is hidden when viewing the form

Thank you for choosing us as your dental care provider.&nbsp; We are committed to protecting our patients’ personal information in a responsible and professional manner.
&nbsp;
Personal information
In order to properly serve you, we must gather personal information.&nbsp; This information helps us open and update your dental file, to invoice patients for services provided, to process credit card payments, or to collect unpaid accounts.&nbsp; It is also necessary to process insurance claims and third-party health benefits.&nbsp; Lastly, we use it to send appointment reminders as well as information about our dental practice.
&nbsp;
Financial Policy
Payment for services rendered are due the day the services have been performed, unless arrangements have been made in advance.&nbsp; If you have dental insurance, we are happy to invoice your insurance company directly on your behalf.&nbsp; In order to provide this service, we ask that a credit card be left on file.&nbsp; Should there be a balance left after your dental insurance has paid their portion, we will send a statement with the balance, and if it is not paid within 30 days, we will charge the credit card on file.&nbsp; Any deductibles or co-payments are due at the time of service.&nbsp; Any portion not paid by your insurance company is your responsibility.&nbsp;
&nbsp;
Insurance Policy
We are happy to provide direct billing to insurance companies for our patients.&nbsp; Please keep in mind that your insurance benefits are a contract between you and your insurance provider, and we are not a party to that contract.&nbsp; Due to the&nbsp;Canadian Personal Privacy Act,&nbsp;we are unable to access any specific information from your insurance company regarding your dental plan.&nbsp; It is your responsibility to know the parameters of your coverage, such as annual maximums, frequencies, renewal dates, and any other limitations.&nbsp;&nbsp; We understand that many patients would like to know their insurance coverage prior to consenting to recommended treatment and are happy to provide pre-determinations when possible.&nbsp; Please understand that these are only estimates and are not a guarantee of insurance payment.&nbsp;&nbsp;&nbsp;
&nbsp;
Appointment Reminders
As a courtesy, we send out reminder emails 1 week prior to a booked appointment, and if unconfirmed, we will send a text message 3 days prior.&nbsp; If the appointment remains unconfirmed, we will call you 1-2 days prior to your appointment.&nbsp; We require an email address and mobile phone number in order to send the reminders.&nbsp; Although we make every effort to contact you prior to any appointment, it is ultimately your responsibility to ensure that you will be at your appointment.&nbsp; Due to a continuous high demand in prime appointment times, we require a minimum of 24 hours’ notice should you need to reschedule or cancel an appointment.&nbsp; Because we value your time, we do not double book our clients.&nbsp;&nbsp;As such, your appointment is valuable time that the dentist or hygienist have&nbsp;reserved specifically for you.&nbsp; In any case where insufficient notice is given a $50.00 missed appointment fee may be charged to you, or we may require you to prepay to reserve your next appointment.
&nbsp;
Medical Information
We collect medical and dental information in order to ensure that we are able to properly treat you as a patient.&nbsp; We may share that information with dental or medical professionals in situations where we are referring you, with your consent, for specialized treatment.&nbsp; Our dental software, ClearDent is one of only two HIIPAA compliant dental software packages available in Canada (as of 2015).
&nbsp;
Our Mission
At Dynamic Dental, our goal is for you to have a pleasant experience in our office.&nbsp; We strive to serve you to the best of our ability in helping you attain a high level of overall oral health.
Dentists are regulated by the Alberta Dental Association and College which may inspect our records and interview our team members as part of its regulatory activities in the public interest.&nbsp; Thank you for understanding our financial/privacy policy.&nbsp; Please let us know if you have questions or concerns.
Permit for Treatment
I consent to the performing of the dental and oral surgical procedures agreed to be necessary and advisable, including the use of local anesthetic as indicated and I will assume the responsibility for fees associated with those procedures.
I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I consent to the collection, use or disclosure of personal information as required for my own or my dependents dental care, as stated above.

Full Legal Name*

Date*

Financial Agreement for Dynamic Dental

Choose one of the following two payment options:*

I will pay in full at the time of service.

Please bill my insurance company directly.

Additional Details:

You may pay in full at the time of service, after which we will submit your dental claim on your behalf and have the insurance company issue the cheque directly back to you.

Many of our clients use a “reward points” type credit card and choose this option so they can collect the reward points.

Additional Details:

We direct bill if your plan allows, this as a courtesy to our patients. Sometimes we will not receive a response from your insurance so we are unable to take the correct portion at the time of your appointment. This is why we require a credit card on file. When we do not receive a response you can do option one or we will take 20% and send an invoice if there is a remaining portion.

Assignment of Benefits from your insurance company will require a valid credit card number to be left on file. This includes dual insurance holders. Once primary and secondary insurance payments have been received by our office, we will process the co-payment and notify the responsible party of the account that such payment has been processed. Direct billing is a courtesy we offer to our patients.

If you have chosen the option to direct bill your insurance company we will require a credit card on file. Please be prepared to provide this at your upcoming appointment.

Credit Card Authorization Form

Click here to open the form.

Insurance Information

Insurance Policy Holder*

First Last

Date of Birth of Insurance Policy Holder*

Name of Insurance Company (ie. Sunlife, Alberta Blue Cross)*

so we can direct bill your insurance.

Please select an option*

I will upload a photo of my insurance card

I will provide the ID/Certificate number and plan/policy/contract/group number

Plan/Policy/Contract/Group Number*

ID/Certificate Number*

Insurance Card (allowed file type: jpg, jpeg, png, pdf)*

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 512 MB.

Name of Secondary Insurance Company

Policy Holder First and Last Name

Date of Birth of Secondary Policy Holder

Please select an option

I will upload a picture of my insurance card

I will provide the ID/Certificate number and plan/policy/contract/group number

Plan/Policy/Contract/Group Number

ID/Certificate Number

Insurance Card (allowed file type: jpg, jpeg, png, pdf)

Max. file size: 512 MB.

Radiographic Release

Patient Name*

I consent to Dynamic Dental releasing my patient records in the event I relocate to another dental practice and they are then requested to be transferred*

Yes

This field is hidden when viewing the form

I consent to Dynamic Dental requesting my patient records from my previous dental clinic*

Yes

This form is to authorize the release of dental radiographs for the following:

Previous dental clinic:

Please have all current Xrays/Panoramic Xrays emailed to: info@dynamicdentalcalgary.com

Authorized Signature*

Date*

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